The World’s Endodontic Newspaper · U.S. Edition Pulp capping.pdf · By Arnaldo Castellucci, MD,...

By Arnaldo Castellucci, MD, DDS

What did we know before MTA?

On no other subject in dentistryhas there been as much written anddiscussed as the maintenance of thevitality of an exposed pulp. Every-thing, including the droppings of the

English sparrow,8 has been tried.At the beginning of the century, to

avoid extirpation at all costs, any at-tempt at maintaining the vitality ofthe pulp was justified, because therewas no way to perform proper en-dodontic therapy and the successrate was higher after pulp cappingas compared to pulpectomy andcanal treatment.Today, however, given the abun-

dant research that has been per-formed, such an attitude is no longeracceptable. The exposed pulp hornmust no longer produce the samefear that it did 50 years ago.Herman5 first introduced the use

of calcium hydroxide in such cases,and Teuscher and Zander27 first de-scribed the formation of the dentinbridge below the treatment. Usinglabeled radioactive calcium, Pisantiand Sciaky19 demonstrated that cal-cium hydroxide does not participateactively in the formation of thedentin bridge, and concluded thatthe calcium of the dentin bridgecame from the bloodstream only.Via36 noted that after 24 months

68.9 percent of the cases that he hadtreated with calcium hydroxide hadfailed, primarily as a result of inter-nal resorption.Ostrom and Lyon17 and Quigley22

also reported high failure rates, inaddition to the observation of zonesof pulp degeneration below thedentinal bridges.Mitchell and Shankwalker14 have de-

scribed the intense calcification thatoccurs in the pulp tissue followingsuch treatment. This phenomenonhas also been described by Baume.3

The quality and quantity of newlyformed dentin is unpredictable.21

Other authors1,18 have shown that theradiopaque zone observed beneaththe site of exposure cannot always berelated to the calcific barrier. Tziafasand Beltes35 have also demonstratedthat many radiopaque zones are infact zones of necrosis present beneaththe capping material. The radiopaquequality of these zones can be attrib-uted to impregnation with calciumsalts, which derive at least in part fromthe capping agents.7,26

From these and other similar re-search, it is clear that, independentof the size of the exposure, pulp cap-ping, when performed in a desperateattempt to maintain the vitality of acondemned pulp, is not only an un-predictable procedure with an un-certain prognosis, but it is also dan-gerous, because it may cause inter-nal resorption, calcific pulp degen-eration, or both. This may make rou-tine endodontic therapy difficult, ifnot impossible, even though it will

shortly be necessary.13

Weine37 states that calcium hy-droxide is the material of choice indirect pulp capping, but if such ther-apy fails and the tooth becomessymptomatic, it may be difficult, ifnot impossible, to treat it by tradi-tional endodontics because of severecalcifications in the root canal,which are frequently associated withinternal resorption, as describedalso by other authors.Seltzer and Bender25 concur with

Weine in stating that sometimes,notwithstanding the formation of thedentinal bridge, the remaining pulpis chronically inflamed and can be-

come necrotic. Internal resorptionhas been found in at least 33 percentof the teeth treated with pulpotomyand calcium hydroxide. In others,complete mineralization with thedisappearance of the remaining pulptissue has been reported. Such min-eralization may obstruct the canal atsuch a point as to complicate its in-strumentation if endodontic therapybecomes necessary in the future.What makes pulpotomy or pulp

capping with calcium hydroxide dan-

AUGUST 2008 www.endo-tribune.com VOL. 3, NO. 8

ENDO TRIBUNEThe World’s Endodontic Newspaper · U.S. Edition

ESMD to hold its firstmagnification congress“To See or Not to See” is the themefor the first Congress of the Euro-pean Society of Microscope Den-tistry (ESMD). The event, for thosewho are interested in worldwide in-novations in the use of magnifica-tion techniques in dentistry, will beheld Sept. 18–20 in Amsterdam.

Page 8

AMED plans its seventhmicroscope meetingThe Academy of Microscopic En-hanced Dentistry (AMED) will takethe technology of the dental micro-scope to the next level at Summit ofthe Masters, its seventh annualMeeting & Scientific Session, to beheld Oct. 30 to Nov. 1 in Scottsdale,Ariz.

Page 8

Medidenta offers cordlessthermal condenser

The Endotec II from Medidenta is acordless thermal endodontic con-denser that makes warm lateral con-densation easier and faster and pro-vides superior adaptation to thecanal wall. It is touch activated forprecise temperature control and hasa patented tip that fits curved canalsand provides calibrated and rapidheating.

0

Direct pulp capping with MTA: a case report

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Inside this issue

Fig. 1: Histologic appearance of a pulp capping procedure. The MTA is at the top of the picture.Vital pulp tissue is surrounded by normal dentin. Between the two is the dentin bridge, which hasformed after the placement of the ProRoot MTA. (Courtesy of Dr. M. Torabinejad).

Dr. Richard Mounce will offer an hourlong Webi-nar covering the design, manufacture, capabilities,sequence and indications for the Twisted File (TF),followed by a real-time question-and-answer ses-sion, on Sept. 9 at 7 p.m. EST. Participants will earnone unit of continuing education credit. The fee isUSD $95. At the end of the Webinar, the participantshould be familiar with:• The biologic objectives of root canal therapy.• The importance and methods of effective bio-

mechanical cleansing of the root canal system.• Effective rotary nickel titanium file utilization with the Twisted File

and prevention of iatrogenic events.As a participant, you require nothing more than an online computer

with audio. After viewing the live event, you will have access to thearchived presentation for 30 days.To register, visit: www.dtiinstitute.com/webinar/Twisted-File/.

SSaaffee,, eeffffiicciieenntt aanndd pprreeddiiccttaabbllee ccaannaall iinnssttrruummeennttaattiioonn wwiitthh tthhee TTwwiisstteedd FFiillee

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gerous is that the pulp tissue is insome way stimulated to become iso-lated from communication with theoutside and thus form the dentinalbridge without knowing when tostop making these calcific deposi-tions. The process of apposition,which is known to be associatedwith resorption, therefore continues.Schultz et al.24 claim that “exposure

of the pulp tissue that occurs duringthe preparation of the cavity requiresa decision as to whether it is better toattempt capping of the pulp or totreat the tooth endodontically.”In a histological assessment of the

success of vital pulp therapies, Mul-laney15 emphasizes the importanceof examining serial sections, sincethe dentin bridge is often incom-plete and areas of necrosis are fre-quently present. He also notes theshortcoming of radiographic exami-nation when used as the solemethod of assessing success, sincesufficient information regarding the

completeness of the dentinal bridgecannot be obtained.Tronstad and Mjor34 also state that,

although the formation of the denti-nal bridge has been used as one ofthe criteria of the success of directpulp capping, it can also occur inteeth with irreversible inflammation.Nevertheless, when the decision is

made to undertake such therapy37

• because of the poor endodonticskill of the dentist,• because of the anatomical chal-

lenges presented by the tooth andthe dentist’s inability to overcomethem, or• because the patient is unable to

afford the fee,the following criteria must be

carefully confirmed:

1) The tooth must not be sensitiveto heat or cold, nor must there bespontaneous pain.2) There should be no pain on pal-

pation or percussion.3) There should be no periapical

radiographic change.4) Marked narrowing of the pulp

chamber or root canal should not bepresent.5) There should be no calcifica-

tions in the pulp chamber.6) There should not be the slightest

suspicion of bacterial infection, sinceasepsis is the most important factorin pulp healing following exposure.9

The indications for direct cappingare therefore drastically reduced tothe following:a) The patient should be young

and well motivated, so that he/shewill easily return for checkups andnecessary radiographs.b) The exposure must be in

healthy dentin and not below caries,and therefore not in infected dentin.c) The maintenance of strict intra-

operative asepsis is mandatory.d) The pulp chamber must be free

of calcifications, which occupyspace and reduce the blood supply

to the pulp tissue which must heal.Finally, Langeland12 is also clear-

ly opposed to indirect capping,which he calls an unacceptableprocedure. The reasons for its ap-parent success, as for direct cap-ping or pulpotomy, are due to theremoval of most of the disintegrat-ed tissue, but the technique is des-tined to fail because of the pres-ence of bacteria and sometimes asmall zone of pulp necrosis that isleft in contact with the cappingagent. The success of any therapydepends on the total removal of allthe disintegrated tissue.In conclusion, the dentist’s efforts

to maintain the vitality of a pulpthat has been exposed are not onlyjustified but obligatory in teethwith an immature apex, especiallyif the exposure is a result of recenttrauma. The treatment of choice insuch cases is undoubtedly pulpoto-my, which is preferable to directpulp capping. This therapy shouldbe considered a provisional thera-py, pending maturation of the apexand root. The pulp must be kept

Pulp capping ENDO TRIBUNE | AUGUST 20082

MTA

ENDO TRIBUNEThe World’s Endodontic Newspaper · U.S. Edition

Frederic Barnett, DMD (Editor-in Chief)Roman Borczyk, DDSL. Stephen Buchanan, DDS, FICD, FACDGary B. Carr, DDSProf. Dr. Arnaldo CastellucciJoseph S. Dovgan, DDS, MS, PCUnni Endal, DDSFernando Goldberg, DDS, PhDVladimir Gorokhovsky, PhDFabio G.M. Gorni, DDSJames L. Gutmann, DDS, PhD (honoriscausa), Cert Endo, FACD, FICD, FADIWilliam “Ben” Johnson, DDSKenneth Koch, DMDSergio Kuttler, DDSJohn T. McSpadden, DDSRichard E. Mounce, DDS, PCJohn Nusstein, DDS, MSOve A. Peters, PD Dr. med dent., MS, FICDDavid B. Rosenberg, DDSDr. Clifford J. Ruddle, DDS, FACD, FICDWilliam P. Saunders, Phd, BDS, FDS, RCS EdinKenneth S. Serota, DDS, MMScAsgeir Sigurdsson, DDSYoshitsugu Terauchi, DDSJohn D. West, DDS, MSD

Editorial Advisory Board

PublisherTorsten R. [email protected]

PresidentEric [email protected]

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Editor-in-Chief Endo TribuneFrederic Barnett, [email protected]

International Editor Endo TribuneProf. Dr. Arnaldo Castellucci

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Published by Dental Tribune America© 2008, Dental Tribune America, LLC.All rights reserved.

DentalTribuneAmericamakeseveryeffort to re-port clinical information and manufacturer’sproduct news accurately, but cannot assume re-sponsibility for the validity of product claims, orfor typographical errors. The publishers also donot assume responsibility for product names orclaims, or statementsmade by advertisers. Opin-ionsexpressedbyauthorsare theirownandmaynot reflect those ofDental TribuneAmerica.

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Fig. 4a: The radiograph shows the first molar only partially erupted(with the mesial cusps) and with a deep decay involving the pulp.The tooth is completely asymptomatic and responds to vitality tests.Note the immature apices.

Fig. 4b: Postoperative radiograph: the decay has been removed andMTA has been gently positioned over the pulp exposure.

Fig. 2: WhiteProRoot MTA(Dentsply TulsaDental, Tulsa,Okla.).

Fig. 3: TheDovgan carriers,specificallydesigned forMTA (QualityAspirators,Duncanville,Texas).

CorrectionsETEndo Tribune strives to maintain theutmost accuracy in its news and clini-cal reports. If you find a factual erroror content that requires clarification,please report the details to Mr. FredMichmershuizen, managing editor, [email protected].

ETUS_0808_01-12.qxd:ETUS1207_01_Title 8/20/08 9:31 AM

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vital, because it must still completeits primary, formative function.Seltzer and Bender25 state that, oncethe development of the root hasbeen completed, the pulp has noreason to remain there. Since itrepresents only a threat because ofthe calcifications and internal re-sorption that may develop, it mustbe removed, and the tooth must betreated endodontically. After all,who can inform the pulp to stayvital and inert inside the root canalafter the dentin bridge has beencompleted and the apical closurehas occurred?

On the other hand, pulp exposurein a tooth with a mature apex mustbe considered an indication for en-dodontic treatment, since, as Rebel23

stated as long ago as 1922, “an ex-posed pulp is a lost organ.”

What we know today

Recently, Dr. Mahmoud Torabine-jad30 of Loma Linda University inCalifornia has developed a new ce-ment, Mineral Trioxide Aggregate(MTA; ProRoot MTA, Dentsply TulsaDental, Tulsa, Okla.) (Figs. 2, 3),which appears to have all of thecharacteristics requested of theideal cement to seal pathways ofcommunications between the pulpand the oral cavity (mechanical andcarious pulp exposures), and be-tween the root canal system and theperiodontium (iatrogenic perfora-tions, open apices, resorbed apices,root-end preparations).

MTA is an endodontic cement thatis extremely biocompatible, capableof stimulating healing and osteoge-nesis, and is hydrophilic. MTA is apowder that consists of fine triox-ides (tricalcium oxide, silicateoxide, bismute oxide) and other hy-drophilic particles (tricalcium sili-cate, tricalcium aluminate, respon-sible for the chemical and physicalproperties of this aggregate), whichset in the presence of moisture. Hy-dration of the powder results in for-mation of a colloidal gel with a pHof 12.5, that solidifies to a hard solidstructure in approximately three tofour hours.30 This cement is differ-ent from other materials currentlyin use because of its biocompatibil-ity, antibacterial properties, mar-ginal adaptation and sealing prop-erties, and its hydrophilic nature.30

In terms of biocompatibility, Kohet al.10,11 and Pitt Ford et al.20 demon-strated the absence of cytotoxicitywhen MTA came in contact with fi-broblasts and osteoblasts, and theformation of dentin bridges whenthe material was used for directpulp capping.

Several in vitro and in vivo exper-iments2,16,29,31–33 have shown thatsealing ability and biocompatibilityof MTA are superior to those ofamalgam, Super-EBA and IRM; dyeand bacterial leakage studies haveconfirmed the sealing ability ofMTA; the cytotoxicity of MTA was

found to be less than that of Super-EBA or IRM.

The characteristic that distin-guishes MTA from other materialsused to date in endodontics is its hy-drophilic properties. Materials usedto repair perforations, to seal theretro-preparation in surgical en-dodontics, to close open apices, or toprotect the pulp in direct pulp cap-

ping, are in-evitably in contactwith blood andother tissue fluids.Moisture may bean important fac-tor due to its po-tential effects onthe physical prop-erties and sealingability of therestorative mate-rials.29 As shownby Torabinejad etal.,29 MTA is theonly material thatis not affected bymoisture or blood

contamination: The presence or ab-sence or blood seems not to affectthe sealing ability of the mineral tri-oxide aggregate. In fact, MTA setsonly in the presence of water.30

MTA has been used also as a pulpcapping material in exposed pulps20

(Fig. 1) and today seems to be thematerial of choice.

Pulp capping is indicated for teeth

with immature apices when thedental pulp is exposed, and thereare no signs of irreversible pulpitis:28

In such cases the exposures must besealed to preserve vitality of thepulp tissue. Recent studies haveshown that MTA stimulates dentinbridge formation adjacent to thedental pulp. Dentinogenesis of MTAcan be due to its sealing ability, bio-compatibility, and alkalinity.20

Faraco and Holland4 demonstratedthat in teeth treated with MTA allbridges were tubular morphological-ly, and in some specimens the pres-ence of a slight layer of necrotic pulptissue was observed in the superficialportion of these bridges. This sug-gested that the material, similarly tocalcium hydroxide, initially causesnecrosis by coagulation in contactwith pulp connective tissue. This re-action may occur because of theproduct’s high alkalinity, whose pH is10.2 during manipulation and 12.5after three hours.30 In a previous arti-


Fig. 4g: Seven-year recall. The MTA just before the restoration.

Figs. 4c–4f: 7-, 22-, 40- and 53-month recall: the roots have completed their development and no sign of pulp calcification is present. The tooth is stillresponding normally to vitality tests.

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Fig. 4c Fig. 4d

Fig. 4e Fig. 4f

Fig. 4h: The tooth has been restored with a composite onlay.

Fig. 4i: Nine-year recall. Note the integrity of the pulp horn and the pulpchamber free of calcifications.


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cle, Holland et al.6 demonstrated thepresence of calcite crystals in contactwith MTA implanted in rat subcuta-neous tissue. Those calcite crystalsattract fibronectin, which is responsi-ble for cellular adhesion and differ-entiation. Therefore we believe thatthe MTAmechanism of action is sim-ilar to that of calcium hydroxide, butin addition, MTA provides a superiorbacteria-tight seal.4

Report

A 6-year-old girl was referredbecause of a deep decay in the

lower right first molar. The toothwas only partially erupted (withthe mesial cusps), while the distalcusps were still unerupted. Themesio-buccal cusp presented adeep decay involving the pulp.The tooth was completely asymp-tomatic and responded to all vital-ity tests. The radiograph showedthat the apices were immature(Fig. 4a).After achieving anesthesia, the

isolation with a rubber dam wasachieved after etching the enamelbuccal and lingual to the mesialcusps and after bonding two littlepieces of composite to stabilize therubber dam clamp. The removal ofthe decayed dentin involved a large

pulp exposure. The exposed pulpwas irrigated with 5 percent NaClOto control bleeding. The MTA pow-der was mixed with sterile water,and the mixture was then placed incontact with the exposure using aDovgan carrier. The mixture wasgently compressed against the ex-posure site with a moist cotton pel-let. A moist cotton pellet was thenplaced over the MTA, and the restof the cavity was filled with a tem-porary filling material (Fig. 4b).After four hours, the patient wasseen again, the rubber dam wasrepositioned, the temporary fillingmaterial and cotton pellet were re-moved, and the set of the materialwas assessed. Then, the tooth wastemporarily restored and the pa-tient was scheduled for regular re-calls (Figs. 4c–4f).After seven years the young pa-

tient was scheduled for the defini-tive restoration. The radiographshowed the complete formation ofthe root apices and the absolute ab-sence of calcifications in the pulpchamber. The pulp horn under thecapping material was intact. Thetooth responded to all the vitalitytests (Figs. 4g–4i).

Conclusion

For sure MTA is to be preferred tothe use of calcium hydroxide andtoday should be considered the ma-terial of choice when a direct pulpcapping is indicated. Nevertheless,MTA has only recently been intro-duced, and no long-term studies onits efficacy have been published yet.Therefore, it is necessary to recalltreated patients on a regular basis todetermine if treatment has beensuccessful, or if root canal therapy isneeded.

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Dr. Arnaldo Castellucci

Dr. Castellucci graduated in Med-icine at the University of Florencein 1973 and specialized in Dentistryat the same University in 1977.From 1978 to 1980 he attended con-tinuing education courses in en-dodontics at Boston UniversitySchool of Graduate dentistry withProf. Herbert Schilder. As well asrunning a practice limited to en-dodontics in Florence, Italy, Dr.Castellucci is past president of theItalian Endodontic Society, past president of the International Federa-tion of Endodontic Associations, an active member of the European So-ciety of Endodontology, an active member of the American Associationof Endodontists, and a visiting professor of endodontics at the Univer-sity of Florence Dental School. He is editor of The Italian Journal ofEndodontics and of The Endodontic Informer, founder and president ofThe Warm Gutta Percha Study Club and The Micro-Endodontic Train-ing Center, and he is international editor of Endo Tribune. An interna-tional lecturer, he is the author of the text “Endodontics,” which is nowavailable in English.

About the author

References1. Barker, B.C.W., Lockett, B.C.: An unusual response by dog pulp to calcium hydrox-

ide. Oral Surg. 32:785, 1971.2. Bates, C.F., Carnes, D.L., Del Rio, C.E.: Longitudinal sealing ability of mineral tri-

oxide aggregate as a root end filling material. J. Endod. 22:575, 1996.3. Baume, L.J.: Diagnosis of disease of the pulp. Oral Surg. 29:102, 1970.4. Faraco, I.M., Holland, R.: Response of the pulp of dogs to capping with mineral tri-

oxide aggregate or a calcium hydroxide cement. Dent. Traumatol. 17:163, 2001.5. Hermann, B.W.: Dentinobliteration der wurzelkanalel nach behandlung mit kalzi-

um. Zahnaertzl. Rundsch. 21:887, 1930.6. Holland, R., De Souza, V., Nery, M.J., Otoboni Filho, J.A., Bernabe, P.F., Dezan Jun-

ior E.: Reaction of rat connective tissue to implanted dentin tubes filled with miner-al trioxide aggregate or calcium hydroxide. J. Endod. 25:161, 1999.

7. Holland, R., Pinheiro, C.E., De Mello, W., Neri, M.J., De Souza, V.: Histochemicalanalysis of the dog’s dental pulp after pulp capping with calcium, barium, andstrontium hydroxides. J. Endod. 8:444, 1982.

8. Hunter, W.C.: Saving pulp, a queer process. Dent. Items Interest, p. 352, 1883.9. Kakehashi, S., Stanley, H.R., Fitzgerald, R.J.: The effects of surgical exposure of den-

tal pulps in germ-free and conventional laboratory rats. Oral Surg. 20:340, 1965.10. Koh, E.T., McDonald, F., Pitt Ford, T.R., Torabinejad, M.: Cellular response to min-

eral trioxide aggregate. J. Endod. 24:53, 1998.11. Koh, E.T., Torabinejad, M., Pitt Ford, T.R., Brady, K.: Mineral trioxide aggregate stim-

ulates a biological response in human osteoblasts. J. Biomed. Mater. Res. 37:432,1997.

12. Langeland, K.: Tissue response to dental caries. Endod. Dent. Traumatol. 3:149,1987.

13. Langeland, K., Dowden, W.E., Tronstad, L., Langeland, L.K.: Human pulp changesof iatrogenic origin. Oral Surg. 32:943, 1971.

14. Mitchell, D.F., Shankwalker, G.B.: Osteogenic potential of calcium hydroxide andother materials in soft tissue and bone wounds. J. Dent. Res. 37:1157, 1958.

15. Mullaney, T.P., Lawson, B.F., Mitchell, D.F.: Pharmacologic treatment of pulpitis: acontinuing investigation. Oral Surg. 21:479, 1966.

16. Nakata, T.T., Bae, K.S., Baumgartner, J.C.: Perforation repair comparing mineraltrioxide aggregate and amalgam. Abs. n° 40. J. Endod. 23:259, 1997.

17. Perreira, J.C., Bramante, C.M., Berbert, A., Mondelli, J.: Effect of calcium hydroxidein powder or in paste form on pulp-capping procedures: histophatologic and radi-

ographic analysis in dog’s pulp. Oral Surg. 50:176, 1980.18. Pisanti, S., Sciaky, I.: Origin of calcium in the repair wall after pulp exposure in the

dog. J. Dent. Res. 43:641, 1964.19. Pitt Ford, T.R., Torabinejad, M., Abedi, H.R., Bakland, L.K., Kariyawasam, S.P.: Min-

eral trioxide aggregate as a pulp capping material. J. Am. Dent. Assoc. 127:1491,1996.

20. Prush, R.J.: Pulp therapy for children and adolescents. In H. Gerstein ed.: Tech-niques in clinical endodontics. W.B. Saunders Company, Philadelphia, 1983.

21. Ostrom, C.A., Lyon, H.W.: Pulpal response to chemically treated heterogeneous bonein pulp capping sites. Oral Surg. 15:362, 1962.

22. Quigley, M.B.: A critical history of the treatment of pulpal exposures. J. Dent. Child.23:209, 1956.

23. Rebel, H.: Über die aussheidung der freigelegten pulps. Vort. 55:1, 1922.24. Schultz, L.C. e coll.: Odontoiatria conservativa. Piccin ed., Padova, 1971.25. Seltzer, S., Bender, I.B.: The dental pulp. 3rd ed. Philadelphia, J.B. Lippincott Com-

pany, 1984.26. Shubic, I., Miklos, F.L., Lapp, R., Draus, F.J.: Release of calcium ions from pulp-cap-

ping materials. J. Endod. 4:242, 1978.27. Teuscher, G.W., Zander, H.A.: A preliminary report on pulpotomy. Northwest Univ.

Bull. 39:4, 1938.28. Torabinejad, M., Chivian, N.: Clinical applications of mineral trioxide aggregate.

J. Endod. 25:197, 1999.29. Torabinejad, M., Higa, R.K., McKendry, D.J., Pitt Ford, T.R.: Dye leakage of four

root-end filling materials: effects of blood contamination. J. Endod. 20:159, 1994.30. Torabinejad, M., Hong, C.U., McDonald, F., Pitt Ford, T.R.: Physical and chemical

properties of a new root-end filling material. J. Endod. 21:349, 1995.31. Torabinejad, M., Hong, C.U., Pitt Ford, T.R., Kettering, J.D.: Cytotoxicity of four

root end filling materials. J. Endod. 21:489, 1995.32. Torabinejad, M., Rastegar, A.F., Kettering, J.D., Pitt Ford, T.R.: Bacterial leakage of

mineral trioxide aggregate as a root end filling material. J. Endod. 21:109, 1995.33. Torabinejad, M., Watson, T.F., Pitt Ford, T.R.: The sealing ability of a mineral tri-

oxide aggregate as a retrograde root filling material. J. Endod. 19:591, 1993.34. Tronstad, L., Mjor, I.A.: Capping of the inflamed pulp. Oral Surg. 34:477, 1972.35. Tziafas, D., Beltes, P.: Pulp capping with calcium hydroxide: diagnostic value of ra-

diographic findings. Endod. Dent. Traumatol. 4:260, 1988.36. Via, W.F.: Evaluations of deciduous molars treated by pulpotomy and calcium hy-

droxide. J. Am. Dent. Assoc. 50:34, 1955.37. Weine, F.S.: Endodontic therapy. 3rd., St. Louis, The C.V. Mosby Company, 1982.

This article is an excerptfrom Dr. Arnaldo Castelluc-ci’s textbook “Endodontics,”which is divided into threevolumes and 35 chapters.Volumes 1 and 2 of this en-dodontic textbook are nowavailable for the first time inEnglish, completely revisedwith new chapters andmany more color illustra-tions. Each volume comescomplete with its own CD-ROM, which includes thecomplete text and illustra-tions in PDF files.To order, contact Il Tri-

dente S.R.L., Viale dei Mille60, 50131 Firenze, Italy,Tel. +39 055 500 1312,Fax +39 055 500 0232,[email protected], or visitwww.iltridente.it.


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Events ENDO TRIBUNE | AUGUST 20088

Upcoming eventsAug. 28–30Exceptional Practice Management WorkshopThe Women of Dentistry CommitteeVillagio Inn & Spa, Napa Valley, Calif.Information: (416) 907-9836; [email protected]

Sept. 9WEBINAR: Predictable Canal Enlargementwith the Twisted FileDr. Richard MounceOnline SeminarInformation: (416) 907-9836; [email protected]

Sept. 12–142008 Fall Scientific SessionCalifornia Dental AssociationSan FranciscoInformation: (312) 440-2500; www.ada.org

Sept. 18-20European Society of Microscope Dentistry (ESMD) CongressNH Grand Hotel Krasnapolsky, AmsterdamInformation: Tel +31 73 690 14 15; Fax +31 73 690 14 17;[email protected]; www.esmd2008.org

Oct. 2WEBINAR:Be THE Exceptional Practice!Dr. Ron SchefdoreOnline SeminarInformation: (416) 907-9836; [email protected]

Oct. 16–19149th Annual Scientific Session and Marketplace ExhibitionAmerican Dental AssociationSan AntonioInformation: (312) 440-2500; www.ada.org

Oct. 21WEBINAR: Cone Beams — A new dimension of dentistryDr. Daniel McEowenOnline SeminarInformation: (416) 907-9836; [email protected]

Oct. 30–Nov. 1Summit of the Masters, seventh annual Meeting & Scientific Sessionof the Academy of Microscope Enhanced Dentistry (AMED)Scottsdale Princess Resort, Scottsdale, Ariz.Information: (260) 249-1028; [email protected];microscopedentistry.com

Nov. 4WEBINAR: Increase Net Revenue, Foster EmployeeConfidence: The Five Keys to Effective EmploymentRelations for the Dental OfficeMichael MooreOnline SeminarInformation: (416) 907-9836; [email protected]

Nov. 6–8American Association of Endodontists 2008 Fall ConferenceImplants in Endodontics—Treatment Planning and Placement TechniquesIntercontinental Mark Hopkins, San FranciscoInformation: (800) 872-3636; (866) 415-9020; www.aae.org; [email protected]

Nov. 28–Dec. 384th Annual Session, Greater New York Dental MeetingJacob K. Javits Convention Center, New YorkInformation: (212) 398-6922; www.gnydm.org

Nov. 30–Dec. 3Dental Tribune Symposia — “Getting Started in ...” SeriesGreater New York Dental MeetingInformation: (416) 907-9836; [email protected]

The first Congress of the Euro-pean Society of Microscope Den-tistry (ESMD) will be held Sept.18–20 at the NH Grand Hotel Kras-napolsky in Amsterdam. The themeof the event, which is aimed at thosewho are interested in worldwide in-novations in the use of magnifica-tion techniques in dentistry, is “ToSee or Not to See.”

The Congress will emphasizepractical applications. Lectures willbe presented with clinical contentin all dental disciplines: preventive,restorative, ergonomics, endodon-tics, periodontics, photography, im-plant dentistry and its periodontalaspects, and the latest sophisticated3-D radiology. Revolutionary 3-Doptical devices and their implemen-tation in everyday dentistry will alsobe covered. According to event or-ganizers, all of the presenters havemicroscope-centered practices andare highly skilled in the applicationof this technology in clinical den-tistry.

“This is a combination never be-fore seen in Europe — and hardlyever elsewhere,” said ESMD Presi-dent Philippe Van Audenhove, LTH.“These three days in Amsterdamwill give participants a 21st centuryupgrade in all dental disciplines.”

The scientific presentations willbegin on Sept. 18 and will continuethrough Sept. 20. The program in-cludes plenty of hands-on work-shops, master classes and plenarysessions. After hours, attendees willhave the opportunity to experienceall that Amsterdam has to offer.

“A jam-packed social programwill allow plenty of opportunities forthe exchange of ideas and opinions,as well as for meeting fellow partic-ipants,” Van Audenhove said.

A targeted group of companieswill be invited to exhibit their prod-ucts and services. Certificates of at-tendance for all participants will beavailable at the registration desk.

For more information on the event,visit www.esmd2008.org.

By Paul Anstey B.Ch.D. Diplomate,American Board of Endodontics

AMED — the Academy of Micro-scopic Enhanced Dentistry — wasfounded in 2001. Its core mission isthat of exposing practitioners to thetrue value of visualization in every-day practice. Just as the break-through of magnification withloupes revolutionized our ability tosee, so has the technology of thedental microscope taken us to thenext level — a new era of precisiondentistry.

There is no better way to stay onthe cutting edge of your field than byattending Summit of the Masters,AMED’s seventh annual Meeting &Scientific Session, to be held Oct. 30to Nov. 1 at the Scottsdale PrincessResort in Scottsdale, Ariz. You will beexposed to the power of the micro-scope via lectures and hands-oncourses presented by some of the

greatest pioneers in the field. Youwill discover firsthand the value ofthis phenomenal technologythrough the options of restorative,periodontal and endodontic courses,where each participant will have achance to begin developing theskills needed to work with thisbreakthrough device.

A new world awaits you at AMED!Come and discover how to trulymaximize your potential, inject anew excitement in your art and sep-arate your practice from the rest.

Visit us at microscopedentistry.comand revive your professional journey.

Amsterdam is host cityfor first ESMD Congress

Microscope dentistry:revolutionizing vision in our field

Amsterdam, host for the upcoming ESMD Congress, is a destination city that offers plenty to see and do.

Do you have general comments or criticism you would like toshare? Is there a particular topic you would like to see morearticles about? Let us know by e-mailing us at [email protected]. If you would like to make any change to yoursubscription (name, address or to opt out) please send us ane-mail at [email protected] and be sure to includewhich publication you are referring to. Also, please note thatsubscription changes can take up to 6 weeks to process.

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The American Association of En-dodontists (AAE) is advising youngathletes to watch their mouths.

“Traumatic dental injuries andknocked out teeth are most often as-sociated with football or hockey, butspring sports, such as soccer andbaseball, can present just as big arisk,” the AAE warned in a press re-lease. Soccer players are nearlyeight times more likely to suffer den-tal injuries than are football players,and nearly 20 percent of baseballplayers will experience a dental in-jury, according to the AAE.

An athlete is 60 times more likelyto suffer a dental injury, such as aknocked out tooth, when not wear-

ing a protective mouth guard, andthe number of sports-related dentalinjuries is rising. As a result, AAE isurging all coaches and parents tomake sure young athletes wearmouth guards for all sports, includ-ing lacrosse, softball, track and field,and gymnastics. Mouth guard usageprevents an estimated 200,000 in-juries a year, the AAE reported.

“Mouth guards are not just for kidsthat play rough contact sports,” saidAAE President Shepard S. Goldstein,DMD. “It is essential that children’steeth be protected from dental injurywhen they play any physical sport.The AAE wants athletes, coachesand parents to know that mouth

guard use is imperative for allsports, even those not commonlythought of as being hazardous.”

Mouth guards are available inthree common varieties: standard,one-size-fits-all mouth guards;mouth-formed boil-and-bite mouthguards; and dentist-made custommouth guards.

“While custom mouth guards pro-fessionally fitted by a dentist offerthe best protection from dental in-jury, using any type of mouth guardhelps to safeguard natural teeth andreduce the chance of dental trau-ma,” the AAE says. “When usingmouth guards, it’s important to prop-erly maintain and clean them to pre-

vent any possible infections.”A person who has had a tooth

knocked out should try to see an en-dodontist within 30 minutes. Al-though it may be possible to save atooth that has been outside themouth for more than 30 minutes,“the chances of success are less thelonger the tooth is out of the mouth.”

The AAE offered the recommenda-tions earlier this year as part of its RootCanal Awareness Week, held March 30to April 5. The annual initiative focus-es on dental education and is part ofthe AAE’s commitment to promotingthe value of preserving natural teeth.

Source: American Association ofEndodontists

ENDO TRIBUNE | AUGUST 2008 News 9

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AAE calls on young athletes to use mouth guards

Dr. Mo K. Kang, a 2002 recipient ofthe American Association of En-dodontists Foun-dation Endodon-tic Educator Fel-lowship Award,was recentlynamed the first-ever EndowedJack WeichmanChairman of En-dodontics at Uni-versity of Califor-nia Los Angeles.

The chair wascreated to support the teaching andresearch activities of an academicendodontist. The UCLA School ofDentistry teaches the specialty to stu-dents in its four-year doctor of dentalsurgery degree program as well as tograduate dentists enrolled in a two-year residency training program.

“The purpose of the Educator Fel-lowship Award is to help outstand-ing residents become academicleaders,” said Dr. Denis E. SimonIII, AAE Foundation president. “Weare extremely proud to have one ofour awardees become such an inte-gral part of a prestigious university,teaching the future of dentistry.”

The Endodontic Educator Fellow-ship Awards were created to recog-nize the critical role that endodonticeducators play in strengtheningtheir specialty and to address theneed for more endodontic special-ists to teach in dental schools. Rep-resentatives from the Foundation’sBoard of Trustees and the AAE’sBoard of Directors worked togetherto develop the concept and guide-lines in 2000, creating a programthat was one of the first of its kindamong the nation’s dental specialtyassociations. Fourteen fellowshipshave been granted since the pro-gram began.

“The Foundation is dedicated tothe continued health and prosperityof the specialty,” said Dr. Simon.

Dr. Mo Kangappointed Weichmanchair in endodontics

Dr. Mo K. Kang


Products ENDO TRIBUNE | AUGUST 200810

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The Endotec II™ from Medi-denta, based in Woodside, N.Y., isa cordless thermal endodonticcondenser that makes warm lat-eral condensation easier andfaster and provides superioradaptation to the canal wall. TheEndotec II is touch activated forprecise temperature control. En-dotec II’s patented tip fits curvedcanals and provides calibrated and rapid heating. It fits any canalpreparation technique and provides a superior 3-D fill of the canal. TheEndotec II is the most cost effective system on the market. A newly de-signed Endotec II will be available Oct. 1.In addition, TGP (tetracycline gutta percha) is also available. The an-

tibiotic-laced filling material inhibits the growth of bacteria in the canal.According to the company, it is “your insurance for endodontic success.”Those who order an Endotec kit receive a free pack of TGP.For more information, contact Medidenta at (800) 221-0750, or visit

www.medidenta.com.

Medidenta offers Endotec IIthermal endodontic condenser

G. Hartzell and Son, based inConcord, Calif., recently an-nounced two new composite in-struments as additions to itsproduct line.

The first item, #CIPCT, hasblades that are very thin, sharp,and flexible for placement ofcomposite interproximally. Thesecond instrument, #BC1/2T,has small tapered tips for poste-rior composite placement andsculpturing.

Both instruments feature agold titanium nitride coating foran extremely fine, smooth sur-face to minimize scratching andthe sticking of composite.

For more information, callthe company at (925) 798-2206 or (800) 950-2206, [email protected], orvisit www.ghartzellandson.com.

G. Hartzelladds twonew products

Coltène/Whaledent, based inCuyahoga Falls, Ohio, recentlyintroduced the Hygenic Canal-Brush®, designed to improve thecleaning of root canals.The CanalBrush is a highly

flexible micro brush made ofpolypropylene, and it can be au-toclaved. Used during root canaltreatments to remove dentin,plaque and other impurities loosened by files and drills, the small andflexible CanalBrush helps clean areas of the root canal that are notreached by files. The use of the CanalBrush along with a rinsing solu-tion increases the cleaning effect of the rinsing solution on the rootcanal surface.The CanalBrush can be used manually, or with a contra-angle hand-

piece at a maximum of 600 rpm.The CanalBrush is the newest addition to the long list of quality prod-

ucts from Coltène/Whaledent, a world leader in the development of in-novative solutions for dentistry.For further information, contact your authorized Coltène/Whaledent

dealer or contact the company directly at (800) 221-3046 or visitwww.coltenewhaledent.com.

Coltène/Whaledent CanalBrushis designed to improve cleaning

ASI Medical’s unique modularcontrol panel allows for yourchoice of styles and brands ofendodontic instruments to beintegrated into an AdvancedEndodontic Systems® unit withoperation from only one footcontrol.ASI has developed a new shield

for installed obturation guns,now available for all units, whichprotects the heated portion of thegun from accidental contact.ASI’s Designer Series pro-

vides a high-tech appearancewith contemporary styling, al-lowing selection of custompaint colors and Silestone®

worktops to provide that finish-ing touch to a treatment room.The Ergo V™ incorporates

ASI’s latest developments in de-livery system technology to pro-vide the utmost in system per-formance and reliability.The system includes pneu-

matic handpiece connections,closed water supply, air-watersyringe and micro air syringe,and it can easily be upgraded.For more information, contact

an ASI Medical representative,call (800) 566-9953 or visitwww.asimedical.net.

ASI designsobturationgun shield


ENDO TRIBUNE | AUGUST 2008 Education 11

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Endodontic alumni, friends and faculty members of the HarvardSchool of Dental Medicine united recently in raising funds for theAlvin A. Krakow post-doc room in the HSDM Research and Educa-tion Building. Joseph Schulz of the class of 1974 and MichaelScianamblo of the class of 1977, co-chairs of the effort, provided theenergy behind the Endodontic Alumni Committee, which wascharged to secure funds to name a room in the Research and Edu-cation Building in honor of Dr. Krakow. The Committee raised near-ly $200,000, personally contacting those who have benefited fromDr. Krakow’s positive impact on their lives. Those who participatedin the room naming will be listed on a plaque inside the AlvinKrakow room. A tribute to Dr. Krakow, pictured, was held on Friday,May 2, in Boston.

Harvard’s endodonticalumni and friendshonor Dr. Alvin A. Krakow

By Laura Mackin, Boston UniversityThe annual Advanced Pro-

grams in Clinical EndodonticsSymposium (APICES) tookplace at Boston UniversityGoldman School of DentalMedicine (BUGSDM) Aug. 1-3.The three-day event was co-founded by Boston Universityresidents Jessica Barr andBrian Chuang in 2004 as a non-profit activity dedicated to pro-viding an educational and so-cial environment specificallyfor endodontic residents.Nidhi Prakash led the

APICES planning committeefor this year’s event, which wascomprised of 13 other first-year residents with additionalguidance provided by APICESveteran BUGSDM Dean ad in-terim Dr. Jeffrey Hutter.“APICES began four years

ago right here at Boston Uni-versity,” said Dr. Prakash. “Iam so proud to bring the sym-posium back to Boston for thefirst time since the inauguralevent.”The event boasted partici-

pants from dental schoolsacross the nation and 12 na-tionally and internationallyrenowned speakers.

APICES returnsto BostonUniversity

From left: Courtney Russell, JeffreyBell, Nidhi Prakash, Michelle Stoffa,Mark Emami and Diana Paczesny.

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